Each new act of mass violence rekindles the debate over how to prevent the next one. When the perpetrators suffer from severe mental illness, the question is how to help before they act – even if they resist treatment.

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By David PierceGateHouse Media

The Herald News, Fall River, MA

By David PierceGateHouse Media

Posted May. 17, 2014 at 6:00 PM

By David PierceGateHouse Media

Posted May. 17, 2014 at 6:00 PM

» Social News

Each new act of mass violence rekindles the debate over how to prevent the next one. When the perpetrators suffer from severe mental illness, the question is how to help before they act – even if they resist treatment.

Forcing a person to undergo any medical treatment is usually illegal, a violation of federal civil rights laws. The exception in most states is when a severely mentally ill person is considered a danger to themselves or others. A mentally ill person can be forced to undergo diagnosis and treatment under certain conditions laid out in state involuntary commitment laws, and some states are examining those laws in an effort to prevent tragedies.

Many families with adults who are severely mentally ill face painful conflicts when the family members refuse to believe they are ill and will not stay in treatment. Some families support involuntary commitment laws to provide more ways for their loved ones to stay in sustained care.

The larger public debate over involuntary commitment occurs each time there is a shooting or other tragedy caused by a severely mentally ill person: The shooting deaths of 32 people on the campus of Virginia Tech. A woman pushed to her death in front of a New York City subway train. Gabby Gifford's crippling injuries. The children and teachers killed at Sandy Hook. These national tragedies usually push reform efforts to change involuntary commitment laws to reach the severely mentally ill before the next tragedy occurs.

Opponents question the ability of the state to determine who poses a risk of violence. Some believe voluntary treatment produces better results.

But the push to reach more potentially dangerous people with severe mental illness has shifted the standards for involuntary commitment in some states. Early positive results from those states, more acts of mass violence and an infusion of federal money to expand involuntary mental health care have states exploring ways to reform their involuntary commitment laws.

Decades of change

Today's involuntary commitment laws grew out of the Community Mental Health Act of 1963 – the last major legislation signed by President John F. Kennedy.

The act's intent was to improve the treatment and quality of life for the mentally ill by getting them out of state mental hospitals for treatment in their own communities. At the time, many patients were confined indefinitely to old, sprawling, understaffed institutions and received little care. Reports of abuse were rampant. The average stay in a mental hospital at that time for someone diagnosed with schizophrenia was 11 years.

New treatment practices, particularly the use of prescribed medications, made treating the severely mentally ill in the community more feasible.

The Community Mental Health Act also was intended to shift resources away from large, regional institutions to community-based treatment programs. Grants were provided for construction of community mental health centers focused on prevention, diagnosis and treatment. Each center was required to provide inpatient and outpatient services, emergency treatment and partial hospitalization.

Page 2 of 5 - This deinstitutionalization movement was aided by other developments, including creation of Medicaid in 1965, which provided federal reimbursements for community care, while restricting payments for mental health care in hospitals.

Successive U.S. Supreme Court decisions – beginning in 1975 – sided with those who argued that the old involuntary treatment laws violated civil rights. States were forced to change their commitment statutes. Almost half now require a history of behavior that demonstrates an immediate danger to self or others before a person can be forced into treatment.

The number of psychiatric beds nationwide fell from a peak of 550,000 beds in the mid-1950s, to about 35,000 beds today. But federal funds promised for community-based programs never materialized. Several states reduced overall spending on mental health services.

Back in their communities, some severely mentally ill exercised their new rights and refused treatment. They became part of an upsurge in the homeless population. Some ended up cycling in and out of jail. And the community mental health centers were slow in coming. Even 50 years later, far fewer community mental health centers have been built than envisioned in 1963.

Doris Fuller is executive director of the Treatment Advocacy Center, a national nonprofit group that promotes involuntary outpatient commitment – and more hospital beds – for those with untreated severe mental illness.

“We're trying to move the needle backwards so that people with the most severe mental illnesses get help again,” Fuller said. “They ended up basically in the prisons, jails, streets, in the emergency rooms.”

All of this brought a renewed focus on involuntary commitment laws. People concerned about public safety and costs to the community, as well as some advocates for the mentally ill, wanted more leeway in involuntary commitment laws to reach more people. And every time another act of mass violence involving a mentally ill person occurs, the debate surges into public view.

Cost of poor treatment

Without a reliable system of community-based mental health care, nor a legal way to compel the severely mentally ill to receive available care, about 3.5 million of the most severely mentally ill today receive no treatment, according to estimates from the National Institute of Mental Health.

The burden of untreated mental illness falls heavily on the individuals, their families and friends. The community also pays a heavy price, particularly when these individuals are chronically homeless, violent or end up in jail.

The most common forms of severe mental illness are schizophrenia and bipolar disorder. Without treatment, sufferers can lose touch with reality and suffer hallucinations or delusions, extreme mood swings, or sink into severe depression.

The shortage of community-based treatment programs shows up in a variety of statistics:

• About half of the 2.6 million adults in the United States with schizophrenia and 40 percent of the 5.1 million U.S. adults with bipolar disorder go untreated, according to the National Institute of Mental Health.

Page 3 of 5 - • Up to one in five inmates in jail and state prisons are mentally ill, according to separate reports by the U.S. Justice Department and American Psychiatric Association.

• About 17.5 percent of inmates in state prisons have schizophrenia, bipolar disorder or major depression, according to the National Commission on Correctional Health Care.

• A history of untreated mental illness was found in 12 percent of murders of a spouse, 16 percent of child killings by a parent, and 25 percent of parents killed by children, according to the Justice Department.

Other studies show that people with untreated mental illness account for up to 50 percent of mass killings.

Mass killings or other highly publicized acts of violence often drive efforts to reform involuntary commitment laws. Many states focus on the first stage of diagnosis and stabilizing treatment that can occur on outpatients. Long-term hospital commitment may follow, or the person may continue outpatient treatment.

Acts of mass violence have provoked calls for implementing more court-ordered involuntary outpatient commitment across the country, in the hope of stopping violence before it happens.

But tougher involuntary outpatient commitment laws wouldn't have stopped most of those people before they killed, contends Curt Decker, executive director of the National Disability Rights Network. The organization was created by Congress in 1986 to represent the rights of the mentally ill in institutions.

“I don't think stigmatizing someone with mental illness is the answer,” Decker said of forcing people into treatment. “I think that drives people away. That's actually the opposite of what people want.”

Reforming the laws

Involuntary outpatient commitment laws vary in their specifics from state to state. But all impose some level of coercion to ensure a severely mentally ill person gets treatment.

Most states with proactive involuntary outpatient commitment laws require a history of past noncompliance with treatment, coupled with past hospitalizations and arrests, before a person can be forced into treatment.

The process usually begins with a court order for someone to submit to an outpatient treatment plan, though statutes stop short of allowing forced medication. Failure to follow a treatment plan may result in a request for police to take the person to a treatment facility for encouragement to either comply or be evaluated for hospitalization.

The intent of the oversight is to ensure someone whose mental condition poses a danger to themselves or others receives treatment long enough for the person to feel better, and once that happens, the person will become a willing participant in recovery.

But involuntary outpatient commitment deprives a person of some personal freedom. It also invokes memories of previous abuses in the old mental health system, in which people were locked away in large state hospitals with little or no treatment.

Page 4 of 5 - Forty-five states have involuntary outpatient commitment laws. Connecticut, Maryland, Massachusetts, New Mexico and Tennessee rely solely on involuntary hospital evaluation and treatment, with no provision for involuntary treatment in the community.

North Carolina revised its involuntary outpatient commitment law in 1984 by expanding the definition of “dangerousness to self” to include the “reasonable probability of his suffering serious physical debilitation within the near future unless adequate treatment is given.”

That old standard of posing a danger has been called “imminent threat.” Someone must pose an imminent threat to self or others based on a recent threat or act.

Whether a person must have a history of dangerous behavior is a key part of the debate over involuntary outpatient treatment and the focus of a number of reforms.

Other states have replaced the imminent threat requirement with a process that allows a court to determine if a person is unlikely to survive safely in the community without supervision. No recent threat or violence is required, just the potential.

New York used that kind of standard to reform its involuntary outpatient commitment laws in 1999 after the two highly publicized subway incidents. The law is called Kendra's Law, named for one of the victims.

In New York, a judge – based on a psychiatrist's written evaluation – can order six months of community treatment for a severely mentally ill person based on a history of noncompliance with treatment, resulting in either hospitalization or jail at least twice during the past three years. The person's history also must include at least one attempt or threat to harm self or others during the past four years.

Florida passed an involuntary outpatient commitment law in 2005, after a sheriff's deputy and a mentally ill man were killed in a standoff. Like North Carolina and New York, Florida law allows involuntary treatment to be imposed before dangerous incidents occur. It can be invoked if the person has had at least two 72-hour involuntary emergency exams during the past three years.

In the first three years, Florida had 42,000 adults fall under the new standard for involuntary outpatient commitment. Yet just 71 commitment orders were issued, perhaps because of a failure to provide more funding for treatment programs. Florida offers few community treatment options, as the state ranked 49 in per capita spending on mental health, according to a 2010 study.

Positive results

Involuntary outpatient commitment standards based on a potential for violence have shown positive results.

Duke University Medical Center studied involuntary outpatient commitment in New York and North Carolina. Both studies pointed to better outcomes for those subjected to involuntary outpatient treatment.

In New York, people who went through involuntary outpatient treatment were less likely to be admitted for hospital treatment. New admissions dropped 25 percent during the first six months of outpatient treatment, and by a third over the second six months, compared to a comparable period before the court orders. The New York study also reported greater use of medications and fewer arrests.

Page 5 of 5 - In North Carolina, people who went through involuntary outpatient treatment also were less likely to be admitted for hospital treatment.

However, critics say those studies failed to measure whether the improved outcomes were due to coercion, or improved treatment options funded when the new laws were passed.

“A system of care that is properly funded would in itself be an alternative” to involuntary commitment, said Yale School of Medicine Professor Michael Rowe.

Rowe studied a Connecticut program that used “peer specialists” (people with mental health histories trained to help others) to provide voluntary care. That program had been approved in 2000 as an alternative to involuntary outpatient commitment. The study found that peer providers were adept at quickly motivating “the most disconnected” to accept mental health care, he said.

The clear trend, however, is for increased use of involuntary outpatient commitment. And much of that increase may turn on reforming the standards for determining who should be in such programs.

Millions of dollars of new federal money is likely to drive this debate across the country in coming months.

In April, President Barack Obama signed a law that authorizes $60 million in grants during the next four years for additional states and localities to implement involuntary outpatient commitment laws. The aim is to fund programs that reduce hospitalization, homelessness and run-ins with the law among the untreated mentally ill by encouraging treatment. Case managers will file petitions to force people into treatment, develop treatment plans and monitor compliance.

U.S. Rep. Tim Murphy, R-Pa., a psychologist, proposed cutting off federal mental health funds to any of the five states without an involuntary outpatient commitment law that fails to enact one. The proposal was part of a larger bill that would overhaul the entire mental health system. An initial hearing on the bill was held in April.

“I'm hearing from thousands of parents from across America, and they need help,” Murphy said. “We want states to do more than just put people in jail or force them into hospitals.”

States like New York, with strong involuntary outpatient commitment laws, have been able to reduce prison and emergency room populations by diverting more people into treatment, he said.

His legislation has the Treatment Advocacy Center's support. Fuller, the center's executive director, says it is more humane to treat those who refuse help than to ignore them as they descend into darkness. She bristles at the suggestion involuntary outpatient commitment is forced treatment.

“That is a misnomer,” she said. “It's not forced. It is leveraged or motivated.”

David Pierce is a reporter for the Pocono Record in Pennsylvania. He researched involuntary treatment for people with severe mental illness for one month as part of GateHouse Media's Pinnacle project reporting training.